Journal of Clinical Psychology Practice

Transcription

1 Journal of Clinical Psychology Practice Content and Diagnostic Specificity of Fear Hierarchy Items of Youth with Anxiety Disorders Kimberly D. Becker University of Maryland School of Medicine Ashley M. Smith University of Miami, Florida Brad J. Nakamura The University of Hawaii at Manoa Bruce F. Chorpita The University of California, Los Angeles Knowledge about children s fears and the clinical phenomenology of anxiety disorders has increased dramatically over the past three decades following the expansion of the anxiety and phobic disorders categories in the DSM-III (American Psychiatric Association, 1980) and the development of the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983). The FSSC-R, the most frequently used fear inventory (Silverman & Hicks-Carmichael, 1999), is an 80-item self-report questionnaire with five factors of fears: danger/death, failure/criticism, the unknown (e.g., going to bed in the dark), small animals, and medical (Ollendick, 1983; Ollendick, King, & Frary, 1989). Research involving a variety of youth samples indicates that most of the top ten fears across samples are related to bodily harm or physical threat (Muris & Ollendick, 2002; Ollendick, 1983; Ollendick, King, & Frary, 1989). Results from the FSSC-R demonstrate robust and generally similar patterns in the frequency and intensity of fears across age, gender, and Summary The current study examined the fear stimuli of 64 youth receiving treatment for one or more anxiety disorders at a university outpatient clinic. Results indicated that the majority of fear stimuli were empirically associated with specific anxiety disorders. Approximately, 68 percent of fear hierarchy items were associated with youths primary anxiety diagnosis, 15 percent were associated with comorbid anxiety disorders, and 17 percent were associated with fears outside of youths diagnostic profiles. Given that one-third of hierarchy items reflect fears not associated with primary anxiety disorders, it may be helpful to consider fear categories related to comorbid and other fears to yield a representative list of stimulus items during exposure treatment among youth. Keywords Fear Hierarchies Item Content Exposure Child Anxiety Contact 2012 (3) Kimberly D. Becker PhD Division of Child & Adolescent Psychiatry University of Maryland School of Medicine 737 W. Lombard Street, # 463 Baltimore MD Telephone: (410) Fax: (410) kbecker@psych.umaryland.edu

2 29 nationality, suggesting that there are common themes among youth with regard to the fears they report. Research involving youth with clinical levels of anxiety suggests that specific fears are associated with each disorder (e.g., Beidel, 1991; Beidel, Turner, & Morris, 1995; Kearney, Albano, Eisen, Allan, & Barlow, 1997; Storch et al., 2009; Weems, Silverman, Saavedra, Pina, & Lumpkin, 1999). For example, youth with Separation Anxiety Disorder (SAD) frequently endorse fears related to separation from home or attachment figures, particularly by getting lost (Last, Francis, & Strauss, 1989). In contrast, worries endorsed by youth with Generalized Anxiety Disorder (GAD) during often involve school, weather-related disasters, bodily harm, future events, and social interactions (Weems, Silverman, & La Greca, 2000). These youth also frequently report worries about making mistakes and perceived failure (Bell-Dolan & Brazeal, 1993; Last et al., 1989). Although empirical evidence provides support for the distinction among anxiety disorders (Birmaher et al., 1997, 1999; Bodden, Bogels, & Muris, 2009; Ebesutani et al., 2010; Langer, Wood, Bergman, & Piacentini, 2010; Spence, 1997), the distinction is neither definitive nor without controversy (Ezpeleta, Keeler, Alaatin, Costello, & Angold, 2001; Weems & Stickle, 2005). The overlap among anxiety disorders is apparent in the endorsement by anxious youth of fears not specific to their anxiety disorder (Beidel et al., 1995; Last et al., 1989; Weems et al., 1999). For example, in one outpatient sample, youth with SoP endorsed fears of the unknown, animals, and death in addition to fear of negative social evaluation (Weems et al., 1999). In the same sample, youth with SP of animals reported more fear of negative social evaluation than of animals (Weems et al., 1999). Taken together, the literature on the fears of anxious youth suggests that there are distinct patterns and foci that can vary depending on the youth s diagnosis but that the associations between fears and diagnoses are not absolute. Exposure and exposure-based therapies have been established as highly effective practices for treating anxiety disorders in children and adolescents (Chorpita et al., 2011; Silverman & Hinshaw, 2008). Exposure involves direct or imagined experience with information or stimuli associated with an anxiety-provoking situation or response (Borkovec & Sides, 1979; Butler, 1985; Foa & Kozak, 1986). Many exposure-based protocols use a graduated hierarchy of increasingly difficult situations germane to the youth s fear to guide exposure exercises (cf. Muris, Merckelbach, Holdrinet, & Sijsenaar, 1998; Murphy & Bootzin, 1973; Sheslow, Bondy, & Nelson, 1983; Silverman, Kurtines, Ginsburg, Weems, Rabian, & Serafini, 1999; Wolpe, 1958). Construction of a fear hierarchy often involves collaboration between the youth and clinician to generate a list of feared stimuli and situations (Barlow & Seidner, 1983; Butler, 1985; Mann & Rosenthal, 1969; Wolpe, 1958). Despite the widespread use of fear hierarchies in exposure-based treatments for youth anxiety, specific information about the items of which fear hierarchies are composed is absent from the literature. For example, the extent to which fear stimuli included on fear hierarchies demonstrate specificity with particular anxiety disorders, as the literature on fears reported by youth with particular diagnoses might suggest, is currently unknown. Moreover, although youth often present for treatment with comorbid anxiety disorders (Walkup et al., 2008; Kendall et al., 2010), there is no information regarding the proportion of fear hierarchy items that reflect primary versus comorbid disorders. Also unknown is the degree of similarity between fear hierarchies of youth with the same diagnosis, as is the extent to which certain feared situations might be included on the hierarchies of most youth regardless of their diagnosis. To address these lacunae the present study examined the fear hierarchies of anxious youth to provide descriptive clinical information about fear stimuli and their association with youth diagnostic profiles.

3 30 Method Participants The sample comprised 64 youth (36 females; 56.2%) between the ages of 5 and 18 (M = 12.3, SD = 3.5) referred for treatment of an anxiety disorder at a university-based outpatient clinic between 1998 and Primary ethnicities of youth as reported by parents included Multiethnic (42.2%), Asian (31.3%), Caucasian (12.5%), Other (6.3%), and Pacific Islander (3.1%). Ethnicity data were missing for 4.6% of the sample. Youth with a primary diagnosis other than anxiety were included in the sample if they received treatment for one or more comorbid anxiety disorders. Diagnoses were determined using the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-IV-C/P; Silverman & Albano, 1996), semi-structured interviews that assess a range of internalizing and externalizing disorders. Approximately 90% of the youth met diagnostic criteria for a primary diagnosis of an anxiety disorder (see Table 1). Primary diagnoses for the remaining 9.5% of youth included disruptive behavior, attention/hyperactivity, and depressive disorders, as well as trichotillomania and selective mutism. These youth were included in the present sample because they received treatment for a secondary diagnosis of anxiety, which for the purposes of the analyses were considered their primary anxiety diagnosis. Thirty-six youth (56.3%) met criteria for at least one comorbid disorder, most commonly another anxiety disorder (n = 31; 48.4%). The number of comorbid disorders ranged from zero to four (M = 1.0, SD = 1.1). Table 1 also displays the number of youth who had each disorder anywhere in their diagnostic profile. Table 1 Sample Diagnostic Information (n = 64) Principal Diagnosis Anywhere in Diagnostic Profile Any Anxiety Disorder 58 (90.5) 64 (100.0) Social Phobia 23 (35.9) 36 (56.3) Generalized Anxiety 8 (12.5) 18 (28.1) Obsessive Compulsive 8 (12.5) 10 (15.6) Panic with or without Agoraphobia 5 (7.8) 5 (7.8) Separation Anxiety 5 (7.8) 11 (17.2) Specific Phobia 5 (7.8) 18 (28.1) Posttraumatic Stress 4 (6.2) 5 (7.8) Depressive Disorders 2 (3.1) 9 (14.1) Attention/Deficit-Hyperactivity 1 (1.6) 4 (6.3) Disruptive Behavior Disorders 1 (1.6) 8 (12.5) Selective Mutism 1 (1.6) 1 (1.6) Trichotillomania 1 (1.6) 1 (1.6) Note. Numbers in parentheses are percentages.

4 31 Measures Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-IV-C/P; Silverman & Albano, 1996). The ADIS-IV-C/P is considered the gold standard for assessing anxiety disorders in youth and has sound psychometric properties (Lyneham, Abbott, & Rapee, 2007; Silverman, Saavedra, & Pina, 2001; Wood, Piacentini, Bergman, McCracken, & Barrios, 2003). Assessment procedures involved two interviews, one with the caregiver(s) and one with the youth for those between the ages of 7 to 17. Interviews were conducted by doctoral level clinical child psychologists and senior doctoral students in clinical psychology who had been trained to reliability using the ADIS-IV-C/P. Using information gained through ADIS-IV-C/P interviews, evaluators assigned impairment ratings (range = 0-8; a rating of 4 or higher indicates clinically significant impairment) for each problem area that was assessed. Primary diagnoses were identified as the disorder for each youth that had the highest impairment rating (i.e., the most serious or disabling disorder). Secondary or comorbid diagnoses included additional diagnoses that had impairment ratings greater than or equal to four. Fear hierarchies (Barlow & Seidner, 1983; Wolpe, 1958). Following assessment, youth enrolled in an exposure-based treatment program for their identified anxiety disorder(s). In collaboration with the therapist, each youth created a fear hierarchy that included items reflecting his or her idiographic anxiety-provoking stimuli. Fear hierarchy items were also solicited from caregivers. Therapists began construction of fear hierarchies by providing psychoeducation about exposure-based treatment for anxiety. Therapists then asked youth to name situations which they regularly avoided or endured with marked distress. Since this occurred during the first treatment session following the assessment, many youth were able to spontaneously generate feared situations, and therapists often reminded youth about fears reported during the assessment as well. For each feared situation, youth provided subjective ratings of anxiety on a scale from 0 (not at all anxious) to 10 (extremely anxious) using a visual fear thermometer. Overall, therapists aimed to capture an array of situations for which youth and caregivers reported a wide breadth of anxiety levels. Therapists were instructed to elicit approximately 10 items for each fear hierarchy, but due to differences in functional impairment and variation in the number and scope of fears across youth, there was considerable variability in the length of fear hierarchies. Fear hierarchies consisted of between 9 and 42 items (M = 16.6, SD = 6.8) items. Fear stimulus codes. Two raters, blind to diagnostic status of the youth, coded each fear hierarchy item (n items = 1,062) using a codebook developed specifically for this study. Items were coded in isolation of each other so as not to bias the coding process. Each item was classified into 1 of 30 separate categories reflecting the fear stimulus identified in each item (see Table 2 for complete list of fear stimuli). A copy of the codebook is available from the authors. The codebook was developed through an iterative and rational process. Initial codes were nominated, defined, and tested on a subset of 10 fear hierarchies from this sample. Through discussion with all study authors, codes were refined, added, and tested on a second subset of 10 fear hierarchies. Inter-rater reliability, assessed using a 2,1 model of intraclass correlations (ICCs;

5 Table 2 Percentage of Items within Each Fear Category Included on the Fear Hierarchies of Youth with and without Primary ADIS-IV Diagnoses Fear Category (total # items) Yes (n=26) SoP OCD GAD SP SAD PD PTSD No (n=38) Yes (n=9) No (n=55) Yes (n=8) No (n=56) Yes (n=7) No (n=57) Yes (n=5) No (n=59) Yes (n=5) No (n=59) Yes (n=4) No (n=60) Animals (20) 11.3*** 1.1 Bodily Functions (2) Bodily Harm (28) 10.0** Bodily Image (1) Contamination (35) 27.5*** 0.2 Costumed Characters (2) 1.7* 0.0 Darkness (34) 23.5*** 0.8 Discarding Things (8) 6.7*** 0.0 Eating (30) 5.0** 1.8 Family Matters (35) Future Events (5) Heights (1) Inanimate Objects (15) 13.0*** 0.0 Loud Noises (2) Mistakes (56) 37.3*** 1.8 Numbers (2) 1.7* 0.0 Order/Routines a (45) 33.3*** 0.6 Performance (119) 23.1*** Religion (10) 5.8*** 0.4 Separation (67) 30.9*** 5.2 Sexual Matters (19) 8.3*** *** 1.1 Small Spaces (13) 4.3* 0.9 Social Situations (333) 61.5*** ** 37.4 Somatic Feelings (23) 23.3*** 0.3 Transportation (31) 9.6*** 2.4 Violence (8) Water (10) *** 0.2 Weather (6) Note. SoP = Social Phobia; OCD = Obsessive Compulsive Disorder; GAD = Generalized Anxiety Disorder; SP = Specific Phobia; SAD = Separation Anxiety Disorder; PD = Panic Disorder with/without Agoraphobia; PTSD = Posttraumatic Stress Disorder. Column percentages do not add up to 100% because items that were coded into categories that were not tested for an association with a particular disorder were not included. ***p <.001; **p <.01; *p <.05. a The fear stimulus represents Lack of Order/Routines.

6 33 Shrout & Fleiss, 1979), was excellent (.90). Following calculation of ICCs, the two coders came to a consensus regarding all discrepant codes. After coding fear hierarchy items according to content, two clinical psychologists and one doctoral student assigned fear stimuli to anxiety disorders using a rational approach based on DSM- IV-TR (American Psychiatric Association, 2000) diagnostic criteria. For example, all three raters agreed that the fear category Contamination converged with OCD, whereas Darkness reflected specific phobia. Inter-rater reliability was assessed using a 2,1 model of intraclass correlations (Shrout & Fleiss, 1979) and yielded an ICC of.93. Following this, the two clinical psychologists came to a consensus regarding all discrepant codes. Information regarding the codes and their corresponding diagnoses is presented in the Results section. Although creation of fear hierarchies during treatment and rational assignment of fear categories to anxiety disorders as part of this study were informed by diagnostic criteria (i.e., ADIS- IV-C/P diagnoses for fear hierarchies; DSM-IV-TR criteria for rational assignments), these processes were completely independent. Coders were completely blind to the diagnoses of youth when reviewing fear hierarchy content and matching fear stimulus categories with corresponding anxiety disorders. Our goal was to provide a description of the convergence between fear hierarchy content and diagnosis; therefore, it was necessary to develop a method by which we could evaluate the fit between item content and diagnosis that is based in the clinical taxonomy used by clinicians. Data Reduction Results The fear stimulus categories of Uncertainty and Sleep were not represented on any fear hierarchies and therefore were not included in the analyses. Of the 1,062 fear hierarchy items coded for the study, 102 (9.6%) were determined to be uncodeable by coding criteria and were also excluded from the analyses. These items reflected ambiguous situations (e.g., going to the mall, sitting in the library, someone passes by your desk ) in which the fear stimulus would have been apparent to the therapist who developed the hierarchy (e.g., going to the mall represented practicing being away from caregiver) but not to independent coders. Analysis Plan The analysis plan included three steps. First, the associations between fear stimulus categories and the diagnoses they were rationally assigned to were examined using cross-tabulations as an index of validity. Next, the percentages of fear hierarchy items that corresponded to each primary diagnosis as well as to comorbid diagnoses in the diagnostic profile were calculated. Finally, descriptive analyses provided the opportunity to examine in depth the relative frequencies of fear stimuli on youths fear hierarchies across diagnostic categories. These analyses also permitted further examination of items that did not demonstrate a unique association with the diagnosis to which they were rationally assigned. Associations between Fear Stimuli and Diagnoses To examine the association between each fear stimulus and the diagnosis(es) rationally assigned to each category a priori by expert coders, chi-square analyses using Fisher s exact test were conducted. Fisher s exact tests yielded significant associations between 20 of 28 fear stimulus

7 34 categories (71.4%) and their respective diagnoses, thereby providing support for the validity of the rational assignments. Table 2 presents the results for these analyses. Fear stimulus categories hypothesized as representative of a particular diagnosis have values in the table and those fear categories that demonstrated empirical support for their validity are indicated by asterisks. For example, Bodily Harm was hypothesized to correspond with GAD and SP, yet the data provided support for an association with only GAD. The values in Table 2 represent the percentage of items in each category that appear on the fear hierarchies with and without each primary diagnosis. For example, the 28 items coded in the Bodily Harm category made up 10.0% of the items on the fear hierarchies of youth with primary GAD compared to 2.0% of the items on the hierarchies of youth with any other primary disorder, suggesting that when Bodily Harm items appear on hierarchies, they are more likely to appear on those of youth with GAD than of youth without GAD. Similar patterns were identified for 20 of the 28 fear categories. Content specificity occurred when items reflecting a particular fear appeared exclusively on the fear hierarchies of youth with the primary diagnosis(es) representative of that fear category. This occurred for 5 categories (i.e., Costumed Characters and Inanimate Objects [SP], Discarding and Numbers [OCD], Sexual Matters [OCD, PTSD]; Table 2). Items from 11 fear categories represented 2.0% or fewer of items on the fear hierarchies of youth with diagnoses other than the one(s) with which the fear stimulus was empirically associated, suggesting these feared situations are relatively specific to the diagnosis of social phobia (i.e., Eating) OCD (i.e., Contamination, Order/Routines, Religion, Sexual Matters), GAD (i.e., Bodily Harm, Mistakes) SP (i.e., Animals, Darkness, Small Spaces, Water), or PD (i.e., Somatic Feelings). In contrast, some fear stimuli did not demonstrate specificity with any anxiety disorders. Four fear categories (i.e., Performance, Separation, Social Situations, Transportation) represented greater than 2.0% of the items on the fear hierarchies of youth with a primary diagnosis other than the one with which the category was empirically associated and were examined further (see section 2.5). Finally, we identified 8 categories (i.e., Bodily Functions, Body Image, Family Matters, Future Events, Heights, Loud Noises, Violence) that, although were assigned to particular diagnoses through rational assignment, did not demonstrate specificity to those diagnoses. Percentage of Items Reflecting Primary, Comorbid, and Other Fears Following examination of the associations among fear stimuli and diagnoses, we examined the extent to which hierarchy items reflected youths diagnostic profiles. Of the 960 codeable items, 68.5% converged with youths primary diagnosis and an additional 14.9% were associated with at least one comorbid disorder. The remaining 16.8% of items represented fear stimuli not empirically associated with any disorder in youths diagnostic profiles. These patterns varied by diagnosis. Specifically, more than 80% of the fear hierarchy items for youth with a primary diagnosis of SoP or OCD reflected stimuli that represented the respective diagnosis (see Table 3). Youth with SP and GAD as their primary diagnosis also had fear hierarchies on which at least 60% of items corresponded with their diagnosis. However, the majority of fear hierarchy items did not reflect the primary diagnosis for youth diagnosed with PD, SAD, and PTSD. Frequency of Fear Stimuli across Diagnoses Table 4 provides the number and percentage of fear hierarchy items representing each fear stimulus, by diagnosis. Percentages were calculated for each disorder when indicated as the

8 35 Table 3 Number and Percentage of Fear Hierarchy Items that Represented Fear Categories that Converged with the Rationally Assigned Diagnosis Diagnosis Primary Full Diagnostic Profile SoP 361 (89.6) 396 (71.0) OCD 100 (83.3) 100 (66.2) SP 77 (70.0) 96 (36.4) GAD 70 (60.9) 147 (50.2) SAD 21 (30.9) 34 (20.7) PD 20 (23.3) 20 (23.3) PTSD 9 (15.5) 9 (12.5) Note. SoP = Social Phobia; OCD = Obsessive Compulsive Disorder; GAD = Generalized Anxiety Disorder; SP = Specific Phobia; SAD = Separation Anxiety Disorder; PD = Panic Disorder with/without Agoraphobia; PTSD = Posttraumatic Stress Disorder. primary disorder as well as when it appeared anywhere in the full diagnostic profile. For example, for youth with a primary diagnosis of SoP (n = 26), the percentage of items across all fear hierarchies that related to Animals was 1.0%, whereas the percentage of items related to Social Situations was 61.5%. Examination of fear stimuli by primary diagnosis indicates that fear hierarchy items spanned 18 fear stimulus categories for youth with GAD, 16 for youth with SP, 14 for youth with OCD, 14 for youth with PD, 14 for youth with SoP, 11 for youth with SAD, and 9 for youth with PTSD. Patterns emerged suggesting variation regarding the frequency with which fear stimuli were included on fear hierarchies across diagnoses. For example, items related to Bodily Harm, Performance, and Social Situations were quite common, appearing on the fear hierarchies for youth across all seven primary diagnostic categories, although the relative frequency of these items varied by diagnosis (e.g., Performance items reflected 23.1% of the items on the fear hierarchies of youth with social phobia compared to less than 1.0% of items on the hierarchies of youth with OCD). In contrast, Costumed Characters, Discarding, Heights, Loud Noises, and Numbers were present on the fear hierarchies for youth with only one of seven primary diagnoses (i.e., SP). Four fear categories (i.e., Performance, Separation, Social Situations, Transportation) did not demonstrate relative specificity with their associated primary diagnosis because they represented greater than 2.0% of the items on the fear hierarchies of youth with a primary diagnosis other than that with which the fear category was associated (Table 2). We examined the distribution of each fear stimulus on fear hierarchies across all the diagnoses to identify additional patterns regarding their inclusion on fear hierarchies. We also examined Family Matters, which was the only category with a large number of items that was not significantly associated with its hypothesized diagnoses, to explore the distribution of items in that category across diagnoses. Table 5 presents the frequencies with which items in these fear stimuli appeared on the fear hierarchies of youth with a primary diagnosis other than that which was empirically associated

9 Table 4 Number (and Percentage) of Fear Hierarchy Items by Fear Categories, within Diagnostic Groups. Content Category SoP OCD GAD SP SAD PD PTSD P n=26 F n=36 P n=9 F n=10 P n=8 F n=18 P n=7 F n=18 P n=5 F n=11 P n=5 F n=5 P n=4 F n=5 Animals 4 (1.0) 9 (1.6) 3 (2.5) 3 (2.0) 1 (0.9) 2 (0.8) 12 (10.4) 16 (5.5) Bodily Functions 2 (0.4) 1 (0.9) 2 (0.7) 1 (1.5) 1 (0.6) Bodily Harm 2 (0.5) 8 (1.4) 2 (1.7) 2 (1.3) 11 (10.0) 21 (8.0) 1 (0.9) 13 (4.4) 4 (5.9) 6 (3.7) 5 (5.8) 5 (5.8) 3 (5.2) 3 (4.2) Bodily Image 1 (0.3) 1 (0.2) Contamination 20 (3.6) 33 (27.5) 33 (21.9) 1 (0.9) 6 (2.3) 1 (0.9) 1 (0.3) 1 (0.6) Costumed Characters 2 (1.7) 2 (0.7) Darkness 3 (0.7) 4 (0.7) 1 (0.9) 2 (0.8) 27 (23.5) 33 (11.3) 2 (2.9) 18 (11.0) 1 (1.2) 1 (1.2) Discarding Things 3 (0.5) 8 (6.7) 8 (5.3) Eating 20 (5.0) 23 (4.1) 5 (4.2) 6 (4.0) 4 (1.5) 1 (0.9) 5 (1.7) 2 (2.9) 10 (6.1) 2 (2.3) 2 (2.3) 1 (1.4) Family Matters 2 (0.5) 14 (2.5) 2 (1. 7) 3 (2.0) 5 (4.5) 21 (8.0) 12 (4.1) 7 (10.3) 8 (4.9) 19 (32.8) 19 (26.4) Future Events 2 (0.5) 3 (0.5) 2 (1.3) 2 (1.8) 2 (0.8) 1 (1.5) 1 (0.6) Heights 1 (0.9) 1 (0.4) 1 (0.3) Inanimate Objects 7 (1.3) 15 (13.0) 15 (5.1) Loud Noises 1 (0.2) 1 (0.9) 1 (0.4) 1 (0.9) 2 (0.7) Mistakes 9 (2.2) 18 (3.2) 41 (37.3) 49 (18.6) 10 (3.4) 2 (2.9) 6 (3.7) 2 (2.3) 2 (2.3) 2 (3.5) 2 (2.8) Numbers 1 (0.2) 2 (1.7) 2(1.3) Order/Routines a 24 (4.3) 40 (33.3) 40 (26.5) 4 (3.6) 4 (1.5) 1 (1.2) 1 (1.2) Performance 93 (23.1) 97 (17.4) 1 (0.8) 4 (2.7) 12 (10.9) 27 (10.2) 2 (1.7) 16 (5.5) 4 (5.9) 16 (9.8) 4 (4.7) 4 (4.7) 3 (5.2) 6 (0.8) Religion 3 (0.5) 7 (5.8) 7 (4.6) 1 (0.9) 6 (2.3) 2 (0.7) 2 (2.3) 2 (2.3) Separation 14 (3.5) 24 (4.3) 1 (0.8) 4 (2.7) 9 (8.2) 15 (5.70) 19 (16.5) 37 (12.6) 21 (30.9) 34 (20.7) 3 (3.5) 3 (3.5) Sexual Matters 10 (8.3) 10 (6.6) 9 (15.5) 9 (12.5) Small Spaces 2 (0.4) 1 (3.8) 5 (4.4) 5 (1.7) 2 (2.9) 2 (1.2) 3 (3.5) 3 (3.5) 3 (5.2) 3 (4.2) Social Situations 248 (61.5) 276 (49.5) 1 (0.8) 21 (13.9) 15 (13.6) 64 (24.2) 8 (7.0) 67 (22.9) 22 (32.4) 58 (35.4) 22 (25.6) 22 (25.6) 17 (29.3) 26 (36.1) Somatic Feelings 2 (0.5) 8 (1.4) 12 (4.5) 12 (4.1) 20 (23.3) 20 (23.3) 1 (1.7) 1 (1.4) Transportation 2 (0.5) 4 (0.7) 1 (0.7) 1 (0.9) 17 (6.4) 11 (9.6) 25 (8.5) 2 (1.2) 16 (18.6) 16 (18.6) 1 (1.7) 2 (2.8) Violence 5 (4.2) 5 (3.3) 1 (0.9) 2 (0.8) 1 (0.9) 3 (1.0) 1 (1.2) 1 (1.2) Water 1 (0.3) 7 (1.3) 1 (0.9) 1 (0.4) 8 (7.0) 10 (3.4) 1 (0.6) Weather 2 (1.8) 6 (2.3) 4 (1.4) 4 (4.7) 4 (4.7) Note. P = Primary diagnosis; F = Full diagnostic profile. SoP = Social Phobia; OCD = Obsessive Compulsive Disorder; GAD = Generalized Anxiety Disorder; SP = Specific Phobia; SAD = Separation Anxiety Disorder; PD = Panic Disorder with/without Agoraphobia; PTSD = Posttraumatic Stress Disorder. Blanks indicate a mean percentage of 0. a The fear stimulus represents Lack of Order/Routines.

10 37 Table 5 Number and Percentage of Items Included on Fear Hierarchies of Youth with Primary Diagnoses Other Than Empirically Validated Diagnosis SoP OCD GAD SP SAD PD PTSD Family Matters 2 (5.7) 2 (5.7) 5 (14.3) b - 7 (20.0) - 19 (54.3) Performance a 1 (3.8) 12 (46.2) 2 (7.7) 4 (15.4) 4 (15.4) 3 (11.5) Separation 14 (30.4) 1 (2.2) 9 (19.6) 19 (41.3) a 3 (6.5) - Social situations a 1 (1.4) a 8 (11.4) 22 (31.4) 22 (31.4) 17 (24.2) Transportation 2 (10.0) - 1 (5.0) a - 16 (80.0) 1 (5.0) Note. SoP = Social Phobia; OCD = Obsessive Compulsive Disorder; GAD = Generalized Anxiety Disorder; SP = Specific Phobia; SAD = Separation Anxiety Disorder; PD = Panic Disorder with/without Agoraphobia; PTSD = Posttraumatic Stress Disorder. a Indicates significant hypothesized associations between diagnosis and fear category. b Represents hypothesized association that did not reach statistical significance. Cells with no value indicate that items representing the fear category were not included on fear hierarchies for the diagnosis. with the fear category. As an example, when found on the fear hierarchy of youths with a diagnosis other than SoP, Performance items were most likely to be found on the hierarchies of youth with GAD. Discussion The primary purpose of this study was to describe the fear stimuli on the fear hierarchies of a sample of youth receiving treatment for anxiety disorders. Specifically, we examined (1) the associations between fear stimuli and diagnoses, (2) the percentage of items reflecting primary, comorbid, and other fears, and (3) frequencies of fear stimuli across diagnoses. In the sections that follow, we review these results in turn. Associations between Fear Stimuli and Diagnoses Results demonstrated that 71.4% of fear stimuli categories were significantly associated with a particular anxiety diagnosis. This means that an item reflecting the fear stimuli was more likely to appear on the fear hierarchy of youth with the associated anxiety disorder than on the hierarchy of youth with any other anxiety disorder. This is not surprising, given that the distinction among anxiety disorders relies in part on the content of the feared stimulus. This finding converges with previous literature that has identified fears associated with particular anxiety disorders (e.g., Last et al., 1989). Knowledge about how fear hierarchy content might vary as a function of the youth s clinical presentation could inform decisions about treatment planning. For example, knowing that items having to do with making mistakes are very common on the fear hierarchies of youth with generalized anxiety disorder but not on those for youth with panic disorder could help guide clinicians to identify fear stimuli most relevant to their clients. This may be particularly helpful to clinicians just learning exposure-based therapies or those who do not have access to assessment tools that probe feared situations using a structured method. However, this is not to say that the

11 38 associations between fear stimuli and diagnoses should be taken for granted. These fear stimuli serve as the context for feared consequences which may vary depending on a youth s disorder. For example, riding a bus may elicit concerns about whether a stranger will be rude or talkative (e.g., SoP), whether the seats are germy (e.g., OCD), or whether the youth will miss the bus (e.g., GAD), to name a few; therefore, assessment of the feared outcome is necessary for accurate clinical diagnosis and appropriate treatment planning. Although the majority of fear stimuli demonstrated relative specificity with a particular diagnosis, there were a number of exceptions. Performance, Separation, and Transportation items frequently appeared on the fear hierarchies of youth diagnosed either with or without the empirically associated disorders. This lack of specificity may occur because there is overlap in the fears of youth with different anxiety disorders (e.g., Beidel et al., 1995; Weems et al., 1999) or perhaps because certain fears are more frequently reported across anxious youth and may be more likely to be offered as a situation to practice during the development of fear hierarchies. It may also be the case that further examination of these fear stimuli categories could identify additional subgroups of fear hierarchy items (e.g., categorizing Social fear stimuli into assertiveness versus general conversation, etc.) that would enhance the specificity of their association with particular anxiety disorders. Six fear stimuli (i.e., Bodily Functions, Bodily Image, Future Events, Height, Loud Noises, Weather) that were expected to converge with a specific diagnosis likely had too few items coded in their categories to produce significant results. It is possible that a larger sample of fear hierarchy item content from these specified categories could yield significant results. The lack of association for Family Matters with GAD and for Violence with PTSD may be due to the way many PTSD fear hierarchy items were written that omitted detailed information about the trauma. For example, a number of items made vague reference to a traumatic incident in the family (e.g., talking to mom about things that have happened to me in the past, and things that she has done to me ) and thus were coded in the Family Matters category, rather than the Violence or Sexual Matters categories that were hypothesized to converge with PTSD. In contrast, items on the fear hierarchies of youth with GAD that were categorized as Family Matters often reflected worries about family relationships (e.g., Worrying that when my parents scold me it means that they do not care about me anymore ). The inclusion of both types of items in the Family Matters category may have diluted its association with GAD and reduced the number of items in the Violence category, thereby weakening its association with PTSD. Percentage of Items Reflecting Primary, Comorbid, and Other Fears Nearly 69% of fear hierarchy items reflected fear stimuli that converged with the primary diagnosis. This finding indicates that clinicians targeted for treatment the fear stimuli that are associated with the greatest severity of symptoms and impairment, as indicated by the primary diagnosis. The finding that across all disorders nearly 32% of fear hierarchy items do not directly represent the primary diagnosis deserves further attention. Results indicated that approximately 15% of these items were related to comorbid disorders. In cases of youth who present with closely related primary and comorbid disorder (e.g., GAD and SoP), it may be appropriate to weight the fear hierarchy with items that reflect shared content to maximize fear reduction in each domain through exposure. However, in other cases in which there is less overlap of fear stimuli (e.g., SoP and SP) general guidelines regarding the relative proportion of items related to primary versus comorbid disorders might suggest that the clinician and youth focus on situations that are germane to the most impairing disorder.

12 39 Approximately 17% of fear hierarchy items were not related to any disorder in the diagnostic profile. The most likely explanation is that these fear stimuli result in subclinical levels of distress and/or impairment that do not warrant a diagnosis. These may be included as easier items on the fear hierarchy whose practice facilitates initial client success during exposure that generates engagement and momentum in treatment. It may also be the case that these stimuli were not reported during the initial assessment, that there were informant discrepancies regarding the degree of impairment evoked by the stimulus, or that clinicians regard the development of the fear hierarchy as a therapeutic activity with less stringent requirements than those of diagnostic assessment. To understand these patterns better, we examined the associations between items and primary diagnosis for each disorder separately. More than 80% of items on the hierarchies of youth with SoP and OCD and more than 60% of items on the fear hierarchies of youth diagnosed with SP and GAD converged with the primary diagnosis. In contrast, much lower percentages of items on the hierarchies of youth with PTSD, PD, and SAD reflected fear stimuli that were empirically associated with those diagnoses as primary disorders. The low convergence for PTSD may be due to the way the fear hierarchy items were written that omitted detailed information about the trauma and therefore reduced the likelihood of an association between Violence and PTSD. For PD and SAD, a plausible explanation is that the fear stimuli represented on the hierarchies of these youth cause impairment in the context of the primary disorder (i.e., PD or SAD). For example, more than 25% of the items on the fear hierarchies of youth with PD or SAD represent Social Situations (Table 4). It is possible that these situations cause impairment for youth due to the fear of uncomfortable somatic feelings happening in public for youth with PD and the fear of interacting with others without the support of a significant other in the case of youth with SAD. Thus, it is reasonable and appropriate to see the primary diagnosis as well as concomitant fears and worries represented on the fear hierarchies of these youth. It may also be the case that the fear hierarchies of the few youth diagnosed with PD or SAD in our sample are not representative of those for youth with PD or SAD in the larger clinical population. Frequencies of Fear Stimuli across Diagnoses We examined the distribution of items from each fear category across disorders. We found that items related to Bodily Harm, Performance, and Social Situations appeared on the hierarchies of youth across all seven primary anxiety disorders. These results converge with the literature supporting the high frequency of these fears reported by youth (Muris & Ollendick, 2002; Ollendick, 1983). These findings suggest that when these fear stimuli are nominated by youth and/or their caregivers for inclusion on fear hierarchies, it would be useful for therapists to probe the degree of impairment related to these fears. It may be that their nomination reflects a fear that a youth rates as eliciting a lot of anxiety, but that the youth acknowledges has a low probability of occurrence and therefore does not result in significant distress or impairment (Muris & Ollendick, 2002). Limitations It is important to consider these results in light of study limitations. The fear hierarchies examined in this study reflect the procedures for developing fear hierarchies established at this particular university outpatient clinic. The absence of strict guidelines for clinicians about fear hierarchy construction leaves open the possibility that these procedures are unique to this clinic and that the results of this study may not generalize anxious youth receiving treatment in other clinics.

13 40 The small sample size, which was made even smaller when we grouped the youth according to primary diagnosis, calls into question the representativeness of their fear hierarchies relative to all youth with that diagnosis. This study represents a first step towards the examination of fear hierarchy content and the procedures could easily be reproduced in other samples to further examine patterns of item content. Our primary indicator of the convergence between youth diagnoses and fear hierarchy content was a rationally-created construct that relied largely on the authors clinical opinion and experience with the DSM-IV (APA, 2000) and clinically anxious youth. Although this opinion was supported empirically through Fisher s exact tests, it is possible that other valid associations between item content and diagnostic categories could be established. Finally, our conclusions are limited by the lack of information regarding actual implementation of the fear hierarchy during exposure. Without fear rating data, we cannot determine whether items reflecting comorbid and other fears are necessary for symptom reduction and improvement in functioning or whether items representing the primary diagnosis are sufficient. This information might provide a stronger basis for guidelines of fear hierarchy construction. Conclusion This study represents a descriptive examination of items included on the fear hierarchies of anxious youth. We found that 71.4% of fear categories were empirically associated with particular primary diagnoses and that some of these associations were exclusive or nearly exclusive. We also found that approximately 68% of fear hierarchy items represented feared situations typical of the youth s primary diagnosis, although there was significant variation in the frequency of item-diagnosis associations across diagnoses. Taken together, these results suggest that feared situations relevant to the primary diagnosis are of course an appropriate starting point for construction of the fear hierarchy but that it may be helpful to consider fear categories related to comorbid and other fears as well to yield a representative list of practicable items. Acknowledgement During the preparation of this manuscript, the first author was supported by the National Institute of Mental Health (T32 MH18834). The authors wish to gratefully acknowledge Sarah Pestle for her assistance with coding item fear categories. Declaration of Interest Bruce F. Chorpita is President of PracticeWise, LLC, a private behavioral health consulting corporation. Kimberly D. Becker and Brad Nakamura are consultants to PracticeWise, LLC. Ashley Smith has no interests to disclose. References American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: Author. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: Author. Barlow, D., & Seidner, A. (1983). Treatment of adolescent agoraphobics: Effects on parent-adolescent relations. Behaviour Research and Therapy, 21, Beidel, D. (1991). Social phobia and overanxious disorder in school age children. Journal of the American

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